What is the Advantage PPO Low Plan?
EMI Health's Advantage PPO Low Plan is a coinsurance plan, which means we share your costs for covered dental services and procedures. Once you've met your deductible, we'll pay a percentage of your bill.
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Children age up to 19** | Adults age 19 and older | |||
Plan Summary | Advantage Plus Network | Out-of-Network | Advantage Plus Network | Out-of-Network |
Services | ||||
Preventive
Oral Exams, Cleanings, Sealants, X-rays, Fluoride
|
100% | 100% up to MAC* | 100% | 100% up to MAC* |
Basic
Fillings, Space Maintainers, Oral Surgery
|
50% | 50% up to MAC* | 50% | 50% up to MAC* |
Major
Crowns, Bridges, Prosthodontics, Endodontics, Periodontics
|
25% | 25% up to MAC* | Not Covered | Not Covered |
Orthodontics
(Medically Necessary / Non-Medically Necessary)
|
50% / Not Covered | 50% / Not Covered | Not Covered | Not Covered |
Waiting Periods | ||||
Preventive | None | |||
Basic (age 19 and older) | 6 Month Waiting Period | |||
Major | None | |||
Orthodontics
(Medically Necessary / Non-Medically Necessary)
|
None / Not Applicable | |||
Deductible (applies to Preventive, Basic and Major) | ||||
Individual | $75.00 | |||
Family Max | $225.00 | |||
Maximums | ||||
Major Annual Max (age 19 and older) | No Maximum | |||
Annual Max per Person (age 19 and older) | $1,000 | |||
Orthodontic Lifetime Max
(Medically Necessary / Non-Medically Necessary)
|
No Maximum / Not Applicable | |||
Pediatric EHB Annual Max | No Maximum | Not Applicable | ||
Pediatric Individual EHB Out-of-Pocket Max | $375 | Not Applicable | ||
Pediatric Family EHB Out-of-Pocket Max | $750 | Not Applicable |
Benefits illustrated are in summary only. Refer to your Dental Policy for a complete description of benefits, limitations and exclusions.
*All Services are subject to Maximum Allowable Charge (MAC). When using a Non-participating Provider, the insured is responsible for all fees in excess of the Maximum Allowable Charge (MAC). Underwritten by Educators Health Plans Life, Accident, and Health, Inc.
**Through the last day of the month in which the Insured turns 19 years of age